Provider Demographics
NPI:1760716922
Name:FRY, KENNETH A (RN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:FRY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43447-0195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1753 SELKIRK ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-3331
Practice Address - Country:US
Practice Address - Phone:419-662-1722
Practice Address - Fax:419-662-1722
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN348952163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse